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01599
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Environmental-
Protection New York City Department of Environmental
Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR
DETERMINATION
Pursuant to the authority granted under:
Article 11 of the New York State Public Health Law; Rules and Regulations For The
Protection From Contamination, Degradation and Pollution Of The New York City Water
Supply :Ind Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR
Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems;
Putnam County Septic Repair Program Plan — March 2005.
DEP Project #,
PCHD Repair# Dj ""
Site Location: -MJ' f" '4 %aAd�'Ad a ryerl-ti T.M.#
31 / -J- -6g
Reason for Joint Review:
Drainage Basin 200' of WC/Wetland _ Repeat Repair in 5 Yrs.
Name of Owner:
Owner's Address:
'191 a�v vV
Drainage Basin of Project Site:
Installer: _� /4 iCr C.r G
General Description, of Sewage System Repair: - k t 4 a 0, e, -%
%a-S /�(Jv .0 0 I,� i, /k,A,, �k eki ✓�ti, -e,,eL C, V,PC,
Dates of Site Inspections and Soils Tests: /
Approved `Incomplete Delegated '1" "Denied
`Required: Soils Tests Repair Sketch
:i :Rcaso
WC /Wetlands Wclls Othcr
Detcrmina tmade by:
2 - 2
e-( Em,inecring Division Date
PUTNAM COUNTY HEALTH DEPARTMENT
0
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_ PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPA9R.
04 YES �® Internal Use Only PEP3ailOT # � - /
LJ & Repair Permit issued in last 5 years L1 Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland Joint Review
SITE LOCATION Y arm fi� XA r—TOWN 1 ,� � TM # J 71
OWNER'S NAME /•iwt i�&Usla.4 S6 PHONE # &-r- 2W-37'`i3
MAILING ADDRESS ifs 3zW /sr». ro %rltr
APPLICANT AhcJ a/,,I,
NWi% & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE &toe- PCHD COMPLAINT #
PROPOSED INSTALLER �w►t.� PHONE #
ADDRESS 37 6 me F51,,, /�� n -7y REGISTRATION /LICENSE # RC 31
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 6\111
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
DA 4, - NnA�91 T� h 11 Gam` ,(` x -,,XA�
lLQ
I, as owner,agree to he conditions stated on this form
SIGNATURE TITLE CQ,/itP/� DATE % 3
(owner)
I, the septic install. r,.;�gree to comply with the conditions of this-permit for the septic system repair
SIGNATURE TITLE _-P� DATE �2 ✓��P�Z
(installer)
Pro sal a ved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
1
Inspector's Signature & Tit Date Expiration Date
I
Repair proposal is in compliance with applicable codes Yes ❑ No li"
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Putnam County Department of Health
Division of Environmental Health Services
// 2 SSTS Repair - Fin 1 Site Inspection
Date: 3 Inspected by: \ -- Installer: 0, a, �a, J- o
Street.Location: 3 a r - cc.r ... Owner:. Go -1
Town: _ �� r.:s e� Repair Permit #: - 0 16 - / �TM # 3-
1. Type of System: Conventional Alternate ❑ Comments:
2. Septic Tank
Yes
I No-N/Al
Comments
a. Septic tank size -1,000 ... 1,250 ... other.....
y(//
b. Septic tank installed level ......................
c. 10, minimum from foundation ..................
d. Distribution Bog
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
trenches
e. Junction Bog - ro erly set .......:....................
f Trenches'
i. System: completely opened for inspection
D jS^ 0^ C,
ii. Length required 2 Y Length installed 2
I,S� 4v s 4, neX
iii. Pie slo a checked ....................... :..........
iv. Installed according to plan .....................
v. 10 ft. from property line - 20 ft - foundations ...
v
'
vi. Size of gravel % -1 '/s " diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
viii. Ends capped .... ...............................
R. Pump or Dosed Systems
3. SewaLye System Area
a. SSTS Area located as per approved plans
b. Fill section -
//
c. Distance from water course /wetlands
4. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. All pipes flush with inside of box .........................
c. Backfill material contains stones <4" diameter ......:..
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
RFSI Rev - 011312
Li
i
No
Fill
.
..............
oil)
(.6
44
-n-le
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Ter,
REBECCA WITTENBERG, RN, BSN
Public Health Director
=s ROBERT MORRIS, PE
Director of Environmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN: 1 n y S V,
FROM: C K- %.' s A4 C &�
PRIORITY - SEPTIC REPAIR
DELEGATION STATUS
FOR
== - SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM a
JOINT REVIE W
PROJECT: X i f� Cro J� s 4& m
LOCATION: 3 8s' f ac-m � /pie,. se�
TOWN: Pa.4rson TM # 19
NOTICE OF COMPLETE APPLICATION: DATE: .a / /a
❑ Within the drainage basins of West Branch, Boyds Corner, or Croton Falls
Reservoirs
❑ Within 500 feet of a reservoir, reservoir stem or control lake.
Pd Within 200 feet of a watercourse or a DEC wetland and appearing on a
subdivision map approved after December 31, 1992
❑ Design flow greater than 1,000 gallons /day.
❑ Commercial SSTS.
SEPTIC REPAIR JOINT REVIEW
ij
II
-- � - -- fir- - - -� - -- -o - - -- -- ---- _- _ -�___1
Lj
ji
PITT &I(1 COUNTY DEPARTMT EINT OF HEALTH
DIVISION OF ENVIRONIVIENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: K1.6 (rD ld-fGr -il Address:
Located at (street): �% .� Fr, a`����eT TiVt 4 Seetion3 V Block Lot b /
11
iVlunicipality: 901- fXi2r% Watershed: &.J� &dr_-�k
SOIL PERCOLATION TEST DATA
oZ /2-✓ � 2- Witnessed by: (,� �' � S � .
Date of Pre-soaking: Date of Percolation Test: 0:1//?
Dole lNo.
Run No.
Time
Start —
Stop
Elapse
Time
(mire.)
Depth to
water from
9rDund
surface
(inches)
Start - Stop
Water
level drop
in inches
Percolation
Rate
min /inch
0
3
5
2
3
4
1
2
I
3
4
5
2
2
3
4
5 1
I
I
I
Notes:
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < 1 min for 1 -36 min/inch, < 2 min for 31 -60 min/inch).
Alt data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97, p; I of
SECTION D. DRAINAGE_
18. Will proposed grading materially alter the natural drainage in this 'or adU scent areas? Yes' No ,
19. V111 groundwater or surface drainage regture special consideration? .. .......:..:
20.• Will gullies, ditches, etc :, be filled- and watercourses be relooated ? :.........:.......4..... 'Yes No
SECTION E. REtKS ' • ,
21. If a common water supply is proposedi has an-inspection beef made of the
-existing or proposed source and facilities ?................ ........................................ ` Yes: No':
Inspection data .. -
22. Do adjacent wells and/or sewage systems exiW .................... ...: ........:...: W yes 10:N4
23. Additional comments
24. Site 6server/inspector and title
25. Date(s).-of pbservation(s)inspection(s)
' TEST PIT PROFILES
-
.Hole r D 9 z Lot #
Hole 'Lot . •
Hole :Lot #
Depth to water '
Depth to water
Depth to water
Depth to mottling•
Depth.to mottling
Depth to mottling
Depth to rock!unp. - _
Depth to rockrunp.
Depth to rocklimp.
G.L.
G.L.
G.L.
0.5 fo'RSo
. 0.5
os
1.;0
l .fl
. 1 ,0
2.0 �c� o� r� )bin„
2.0 -
Z-0
3.0•
3.0
3.0 • .
4.0 �s ����,'t.t, Sin
4.0
4.0
5.0lc,�
5.0 •
5.0
.6.0
6.0
6.0 '
X1.0
.•
.. :. .
7.0
?.0
.8.0
8.0
8.0
9.0 9:0 9.0
~` 10.0 10.0
PIT 1NAM COUNTY Y DEPARTAMNT OF. HEALTH
Y
DIVISION 'OF ENVIRONNVIENfAL HEALTH SERVICES
IlVZTIAL INDIVIDUAL /COMMERCLkL SITE INSPECTION FORM.
SECTION A.' GENERAL INFORMATION
Name of Project. &0 k S _AA (T)(V) -e ri g.-\... county; �v _
Site Locatioli., Sr f c.Cr--, 4 rrc
Building construction begun ,Extent
Is property within NYC Watershed ? ................. Yes No
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. EE -'Hilly Rolling' 0 Steep slope Gentle slope . Flat '
.2. Evidence of .wetlands Low area subject to flooding Bodies of water
Drainage ditches Rock outcrops
3. Property lines or comers evident ..........i .......::... .....:.:....................... 'des No
4... 'Do water courses exist-on or. adjoin- th6property? ......... ... Yet . No
5. Will these affect the design of the sewage system facilities ?............ Yes' =. .No
6, Do watershed regulations apply in this development ? ....................... Yes No
7 . Will extensive grading be necessary ?.. .............:....... , ................. Yes No
_w
ry a
g-- -Qi%rll exterisiv fill'be necessa for SS'fS7.:.:......`.� 4 yes - es
No
9. Do -filled areas exist within the SSTS area? ........ ............:.................. Yes . No
If yes, what is. the condition of the fill?
SECTION C. SOIL OBSERVATIONS
10. Appearance of soil: Sand. Gravel Loam Clay Q Hardpan .Mixture .
12. Soil borings /excavations observed by e—\\ .� e—\\. A;
13. Depth'to groundwat.°r 40 on
.14. Depth to mottling on
16. Are test holes represYntative of primary & reserve areas .....: ...............................
Ft
Yes No
1.6...Soil percolation tests made by c, . on Z Z
17. Soil percalation tests witnessed by on
SECTION D (on back)
Form ST -1
sEc d O \ D. DK. WAGE_ •
• • 1
18. Will proposed grading materially alter the natural drainage in thi's or
adja.cerd areas? Yes
No
19. Will groundwater or surface drainage require special consideration? ......................
20.- Will gullies, ditches, etc:, be filled and watercourses be relocated ? ........................
Yes
No
SECTION E. RFKA S. ,'
21. If a common water supply is proposed; has aninspection been made
of the
existing or proposed source and facilities ? ...... ....................... ................. . Yes: '
a No '
Inspection data
.No
22. Do adjacent wells and/or sewage systems exist? ................ .......:...:'...:.............. ..
Yes
23. Additional comments -
" 24. ' Site observerAnspector and title
25. Date(s)-of observafion(s)inspection(s)
TEST PIT PROFILES
-
Hole r D Z Lot Holy Lot �.
Hole r Lot r
Depth to water 0 ` Depth to water .
Depth to wato er.
-
15egth to mottling Depth a' mottling
Depth to mottling
.
Depth to rocklim -
p p � � � Depth to rock/imp.
Depth to rock/imp.
.
G.L. G.L.
G.L.
G.5 - -/o jo, .0.5
ti
0.5
Lo ..1.0.
.1.0
2.0 17v 2.0
2*.0
3.0'
3.0 ..
4.0 is e^ T �r���s t, Sin 4.0
4.0
5.0 CJC�� 5.0 •
5.0
.6.0 6.0
6.0
10l.0
7.0
7.0
.8.0 8.0
8.0
9.0 9.0
9.0
10.0. 10.0
10.0
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